Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who is being treated with lithium carbonate for bipolar disorder type I begins to develop diarrhea, vomiting, and drowsiness. Which action should the registered nurse take?
Select one:
A. Hold the medication and refuse to administer additional doses for 3 days.
Option a. Hold the medication and refuse to administer additional doses for 3 days is not an appropriate action because it does not involve notifying the health care provider or obtaining new orders.
B. Notify the health care provider immediately and give 4 liters of fluids.
Option b. Notify the health care provider immediately and give 4 liters of fluids is not an appropriate action because it involves administering fluids without obtaining orders from the health care provider.
C. Prior to giving the next dose, notify the health care provider of these symptoms and hold the next dose until new orders from provider.
Diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity, which can be a serious and potentially life-threatening condition. If a client who is being treated with lithium carbonate develops these symptoms, the nurse should notify the health care provider immediately and hold the next dose of medication until new orders are received from the provider.
D. Document the client's symptoms and continue with medication as prescribed.
Option d. Document the client’s symptoms and continue with medication as prescribed is not an appropriate action because it does not involve notifying the health care provider or holding the next dose of medication.
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health - Proctored Exam 2. Take the full exam now
Full Explanation
Diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity, which can be a serious and potentially life-threatening condition. If a client who is being treated with lithium carbonate develops these symptoms, the nurse should notify the health care provider immediately and hold the next dose of medication until new orders are received from the provider.
Option a. Hold the medication and refuse to administer additional doses for 3 days is not an appropriate action because it does not involve notifying the health care provider or obtaining new orders.
Option b. Notify the health care provider immediately and give 4 liters of fluids is not an appropriate action because it involves administering fluids without obtaining orders from the health care provider.
Option d. Document the client’s symptoms and continue with medication as prescribed is not an appropriate action because it does not involve notifying the health care provider or holding the next dose of medication.
Similar Questions
A registered nurse is admitting a client to an alcohol abuse program. The client states, here because of my boss. It was part of my job to go to parties and drink with clients. The client's statement is an example of which of the following defense mechanisms?
Select one:
A. Compensation
Option a. Compensation is a defense mechanism in which a person attempts to make up for a perceived weakness or deficiency by excelling in another area.
B. Suppression
Option b. Suppression is a defense mechanism in which a person consciously chooses to avoid thinking about or dealing with unpleasant thoughts or feelings.
C. Rationalization
Rationalization is a defence mechanism in which a person attempts to justify or explain their behavior or actions in a way that makes them seem more acceptable or reasonable. In this case, the client is using rationalization by attributing their alcohol abuse to their job and the need to drink with clients at parties.
D. Reaction-formation
Option d. Reaction-formation is a defense mechanism in which a person behaves in a way that is opposite to their true feelings or desires.
Full Explanation
Rationalization is a defence mechanism in which a person attempts to justify or explain their behavior or actions in a way that makes them seem more acceptable or reasonable. In this case, the client is using rationalization by attributing their alcohol abuse to their job and the need to drink with clients at parties.
Option a. Compensation is a defense mechanism in which a person attempts to make up for a perceived weakness or deficiency by excelling in another area.
Option b. Suppression is a defense mechanism in which a person consciously chooses to avoid thinking about or dealing with unpleasant thoughts or feelings.
Option d. Reaction-formation is a defense mechanism in which a person behaves in a way that is opposite to their true feelings or desires.
A psychiatric registered nurse best implements the ethical principle of autonomy when he or she:
Select one:
A. suggests that two patients who have been fighting stay in their rooms.
Option a suggests that the nurse is imposing their own decision on the patients, which violates the principle of autonomy.
B. explores alternative solutions with a patient, who then makes his/her own choice among the alternatives
The ethical principle of autonomy refers to an individual's right to make decisions about their own healthcare, treatment, and life choices. As a registered nurse, it is important to respect and promote the autonomy of patients. Option b best exemplifies the implementation of the ethical principle of autonomy because it involves exploring alternative solutions with the patient and allowing them to make their own choice among those alternatives. This approach respects the patient's right to make decisions about their own care, while also ensuring that they have the information they need to make an informed decision.
C. stays with a patient who is demonstrating a severe level of anxiety.
Option c may involve staying with the patient to provide support and reassurance, but it does not necessarily involve promoting the patient's autonomy.
D. intervenes when a self-mutilating patient attempts to harm him/herself.
Option d involves intervening to prevent harm to the patient, which may be necessary at times but is not necessarily an example of promoting the patient's autonomy.
Full Explanation
The ethical principle of autonomy refers to an individual's right to make decisions about their own healthcare, treatment, and life choices. As a registered nurse, it is important to respect and promote the autonomy of patients. Option b best exemplifies the implementation of the ethical principle of autonomy because it involves exploring alternative solutions with the patient and allowing them to make their own choice among those alternatives. This approach respects the patient's right to make decisions about their own care, while also ensuring that they have the information they need to make an informed decision.
Option a suggests that the nurse is imposing their own decision on the patients, which violates the principle of autonomy.
Option c may involve staying with the patient to provide support and reassurance, but it does not necessarily involve promoting the patient's autonomy.
Option d involves intervening to prevent harm to the patient, which may be necessary at times but is not necessarily an example of promoting the patient's autonomy.
A psychiatric nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
A. "Have you talked to your friends about this yet?"
Option a "Have you talked to your friends about this yet?" may not be an appropriate response, as the client may need more professional support than what their friends can provide.
B. "I have problems too, everybody has problems."
Option b "I have problems too, everybody has problems" may be dismissive of the client's concerns and may not help them feel heard or understood.
C. "How long has this been going on?
This response acknowledges the client's concerns and invites further discussion about their experience. The nurse can use this information to assess the severity and duration of the client's symptoms, as well as any potential triggers or stressors that may be contributing to their anxiety and inability to concentrate.
D. "Have you talked to your parents about this yet?
Option d "Have you talked to your parents about this yet?" may not be an appropriate response, as the client may not feel comfortable discussing their concerns with their parents or may need more professional support than what their parents can provide.
Full Explanation
This response acknowledges the client's concerns and invites further discussion about their experience. The nurse can use this information to assess the severity and duration of the client's symptoms, as well as any potential triggers or stressors that may be contributing to their anxiety and inability to concentrate.
Option a "Have you talked to your friends about this yet?" may not be an appropriate response, as the client may need more professional support than what their friends can provide.
Option b "I have problems too, everybody has problems" may be dismissive of the client's concerns and may not help them feel heard or understood.
Option d "Have you talked to your parents about this yet?" may not be an appropriate response, as the client may not feel comfortable discussing their concerns with their parents or may need more professional support than what their parents can provide.
Option e "Why do you think you are so anxious?" may be seen as confrontational and may not help the client feel heard or understood.
Option f "It sounds like you're having a difficult time" acknowledges the client's concerns but does not invite further discussion or provide an opportunity for the nurse to gather more information.
